The Virtues of Placebo Effects
“I am just a humble historian,” he told the 300 members of the
Society for Interdisciplinary Placebo Studies who had gathered in
Leiden’s ornate municipal concert hall, “so I don’t know anything about
your topic.” He was being a little disingenuous.
He knew enough about
the topic that these psychologists and neuroscientists and physicians
and anthropologists and philosophers had come to his city to talk about —
the placebo effect, the phenomenon whereby suffering people get better
from treatments that have no discernible reason to work — to call it
“fake medicine,” and to add that it probably works because “people like
to be cheated.” He took a beat. “But in the end, I believe that honesty
will prevail.”
The layout in the Dutch city of Leiden is a broad and colorful
ceremonial necklace that, draped around the shoulders of its Mayor Henri
Lenferink, lends a magisterial air to official proceedings in this
ancient university town. But whatever gravitas it provided Lenferink as
he welcomed a group of researchers to his city, he was quick to undercut
it.
Lenferink might not
have been so glib had he attended the previous day’s meeting on the
other side of town, at which two dozen of the leading lights of placebo
science spent a preconference day agonizing over their reputation — as
purveyors of sham medicine who prey on the desperate and, if they are
lucky, fool people into feeling better — and strategizing about how to
improve it. It’s an urgent subject for them, and only in part because,
like all apostate professionals, they crave mainstream acceptance. More
important, they are motivated by a conviction that the placebo is a
powerful medical treatment that is ignored by doctors only at their
patients’ expense.
And after a
quarter-century of hard work, they have abundant evidence to prove it.
Give people a sugar pill, they have shown, and those patients —
especially if they have one of the chronic, stress-related conditions
that register the strongest placebo effects and if the treatment is
delivered by someone in whom they have confidence — will improve. Tell
someone a normal milkshake is a diet beverage, and his gut will respond
as if the drink were low fat. Take athletes to the top of the Alps, put
them on exercise machines and hook them to an oxygen tank, and they will
perform better than when they are breathing room air — even if room air
is all that’s in the tank. Wake a patient from surgery and tell him
you’ve done an arthroscopic repair, and his knee gets better even if all
you did was knock him out and put a couple of incisions in his skin.
Give a drug a fancy name, and it works better than if you don’t.
You
don’t even have to deceive the patients. You can hand a patient with
irritable bowel syndrome a sugar pill, identify it as such and tell her
that sugar pills are known to be effective when used as placebos, and
she will get better, especially if you take the time to deliver that
message with warmth and close attention. Depression, back pain,
chemotherapy-related malaise, migraine, post-traumatic stress disorder:
The list of conditions that respond to placebos — as well as they do to
drugs, with some patients — is long and growing.
But
as ubiquitous as the phenomenon is, and as plentiful the studies that
demonstrate it, the placebo effect has yet to become part of the
doctor’s standard armamentarium — and not only because it has a
reputation as “fake medicine” doled out by the unscrupulous to the
credulous. It also has, so far, resisted a full understanding, its
mechanisms shrouded in mystery. Without a clear knowledge of how it
works, doctors can’t know when to deploy it, or how.
Not
that the researchers are without explanations. But most of these have
traditionally been psychological in nature, focusing on mechanisms like
expectancy — the set of beliefs that a person brings into treatment —
and the kind of conditioning that Ivan Pavlov first described more than a
century ago. These theories, which posit that the mind acts upon the
body to bring about physical responses, tend to strike doctors and
researchers steeped in the scientific tradition as insufficiently
scientific to lend credibility to the placebo effect. “What makes our
research believable to doctors?” asks Ted Kaptchuk, head of Harvard
Medical School’s Program in Placebo Studies and the Therapeutic
Encounter. “It’s the molecules. They love that stuff.” As of now, there
are no molecules for conditioning or expectancy — or, indeed, for
Kaptchuk’s own pet theory, which holds that the placebo effect is a
result of the complex conscious and nonconscious processes embedded in
the practitioner-patient relationship — and without them, placebo
researchers are hard-pressed to gain purchase in mainstream medicine.
But
as many of the talks at the conference indicated, this might be about
to change. Aided by functional magnetic resonance imaging (f.M.R.I.) and
other precise surveillance techniques, Kaptchuk and his colleagues have
begun to elucidate an ensemble of biochemical processes that may
finally account for how placebos work and why they are more effective
for some people, and some disorders, than others. The molecules, in
other words, appear to be emerging. And their emergence may reveal
fundamental flaws in the way we understand the body’s healing
mechanisms, and the way we evaluate whether more standard medical
interventions in those processes work, or don’t. Long a useful foil for
medical science, the placebo effect might soon represent a more
fundamental challenge to it.
In a way,
the placebo effect owes its poor reputation to the same man who cast
aspersions on going to bed late and sleeping in. Benjamin Franklin was,
in 1784, the ambassador of the fledgling United States to King Louis
XVI’s court. Also in Paris at the time was a Viennese physician named
Franz Anton Mesmer. Mesmer fled Vienna a few years earlier when the
local medical establishment determined that his claim to have cured a
young woman’s blindness by putting her into a trance was false, and
that, even worse, there was something unseemly about his relationship
with her. By the time he arrived in Paris and hung out his shingle,
Mesmer had acquired what he lacked in Vienna: a theory to account for
his ability to use trance states to heal people. There was, he claimed, a
force pervading the universe called animal magnetism that could cause
illness when perturbed. Conveniently enough for Mesmer, the magnetism
could be perceived and de-perturbed only by him and people he had
trained.
Mesmer’s method was strange,
even in a day when doctors routinely prescribed bloodletting and poison
to cure the common cold. A group of people complaining of maladies like
fatigue, numbness, paralysis and chronic pain would gather in his
office, take seats around an oak cask filled with water and grab on to
metal rods immersed in the water. Mesmer would alternately chant, play a
glass harmonium and wave his hands at the afflicted patients, who would
twitch and cry out and sometimes even lose consciousness, whereupon
they would be carried to a recovery room. Enough people reported good
results that patients were continually lined up at Mesmer’s door waiting
for the next session.
It
was the kind of success likely to arouse envy among doctors, but more
was at stake than professional turf. Mesmer’s claim that a force existed
that could only be perceived and manipulated by the elect few was a
direct challenge to an idea central to the Enlightenment: that the truth
could be determined by anyone with senses informed by skepticism, that
Scripture could be supplanted by facts and priests by a democracy of
people who possessed them. So, when the complaints about Mesmer came to
Louis, it was to the scientists that the king — at pains to show himself
an enlightened man — turned. He appointed, among others, Lavoisier the
chemist, Bailly the astronomer and Guillotin the physician to
investigate Mesmer’s claims, and he installed Franklin at the head of
their commission.
To the Franklin
commission, the question wasn’t whether Mesmer was a fraud and his
patients were dupes. Everyone could be acting in good faith, but belief
alone did not prove that the magnetism was at work. To settle this
question, they designed a series of trials that ruled out possible
causes of the observed effects other than animal magnetism. The most
likely confounding variable, they thought, was some faculty of mind that
made people behave as they did under Mesmer’s ministrations. To rule
this out, the panel settled upon a simple method: a blindfold. Over a
period of a few months, they ran a series of experiments that tested
whether people experienced the effects of animal magnetism even when
they couldn’t see.
One
of Mesmer’s disciples, Charles d’Eslon, conducted the tests. The panel
instructed him to wave his hands at a part of a patient’s body, and then
asked the patient where the effect was felt. They took him to a copse
to magnetize a tree — Mesmer claimed that a patient could be treated by
touching one — and then asked the patient to find it. They told patients
d’Eslon was in the room when he was not, and vice versa, or that he was
doing something that he was not. In trial after trial, the patients
responded as if the doctor were doing what they thought he was doing,
not what he was actually doing.
It was
possibly the first-ever blinded experiment, and it soundly proved what
scientists today call the null hypothesis: There was no causal
connection between the behavior of the doctor and the response of the
patients, which meant, as Franklin’s panel put it in their report, that
“this agent, this fluid, has no existence.” That didn’t imply that
people were pretending to twitch
or cry out, or lying when they said they felt better; only that their
behavior wasn’t a result of this nonexistent force. Rather, the panel
wrote, “the imagination singly produces all the effects attributed to
the magnetism.”
When the panel gave
d’Eslon a preview of its findings, he took it with equanimity. Given the
results of the treatment (as opposed to the experiment), he opined, the
imagination, “directed to the relief of suffering humanity, would be a
most valuable means in the hands of the medical profession” — a subject
to which these august scientists might wish to apply their methods. But
events intervened. Franklin was called back to America in 1785; Louis
XVI had bigger trouble on his hands and, along with Lavoisier and
Bailly, eventually met with the short, sharp shock of the device named
for Guillotin.
The panel’s report was
soon translated into English by William Godwin, the father of Mary
Shelley. The story spread fast — not because of the healing potential
that d’Eslon had suggested, but because of the implications for science
as a whole. The panel had demonstrated that by putting imagination out
of play, science could find the truth about our suffering bodies, in the
same way it had found the truth about heavenly bodies. Hiving off
subjectivity from the rest of medical practice, the Franklin commission
had laid the conceptual foundation for the brilliant discoveries of
modern medicine, the antibiotics and vaccines and other drugs that can
be dispensed by whoever happens to possess the prescription pad, and to
whoever happens to have the disease. Without meaning to, they had
created an epistemology for the healing arts — and, in the process,
inadvertently conjured the placebo effect, and established it as that to
which doctors must remain blind.
It
wouldn’t be the last time science would turn its focus to the placebo
effect only to quarantine it. At a 1955 meeting of the American Medical
Association, the Harvard surgeon Henry Beecher pointed out to his
colleagues that while they might have thought that placebos were fake
medicine — even the name, which means “I shall please” in Latin, carries
more than a hint of contempt — they couldn’t deny that the results were
real. Beecher had been looking at the subject systematically, and he
determined that placebos could relieve anxiety and postoperative pain,
change the blood chemistry of patients in a way similar to drugs and
even cause side effects. In general, he told them, more than one-third
of patients would get better when given a treatment that was,
pharmacologically speaking, inert.
If
the placebo was as powerful as Beecher said, and if doctors wanted to
know whether their drugs actually worked, it was not sufficient simply
to give patients the drugs and see whether they did better than patients
who didn’t interact with the doctor at all. Instead, researchers needed
to assume that the placebo effect was part of every drug effect, and
that drugs could be said to work only to the extent that they worked
better than placebos. An accurate measure of drug efficacy would require
comparing the response of patients taking it with that of patients
taking placebos; the drug effect could then be calculated by subtracting
the placebo response from the overall response, much as a deli-counter
worker subtracts the weight of the container to determine how much
lobster salad you’re getting.
In the
last half of the 1950s, this calculus gave rise to a new way to evaluate
drugs: the double-blind, placebo-controlled clinical trial, in which
neither patient nor clinician knew who was getting the active drug and
who the placebo. In 1962, when the Food and Drug Administration began to
require pharmaceutical companies to prove their new drugs were
effective before they came to market, they increasingly turned to the
new method; today, virtually every prospective new drug has to
outperform placebos on two independent studies in order to gain F.D.A.
approval.
Like Franklin’s commission,
the F.D.A. had determined that the only way to sort out the real from
the fake in medicine was to isolate the imagination. It also echoed the
royal panel by taking note of the placebo effect only long enough to
dismiss it, giving it a strange dual nature: It’s included in clinical
trials because it is recognized as an important part of every treatment,
but it is treated as if it were not important in itself. As a result,
although virtually every clinical trial is a study of the placebo
effect, it remains underexplored — an outcome that reflects the fact
that there is no money in sugar pills and thus no industry interest in
the topic as anything other than a hurdle it needs to overcome.
When Ted Kaptchuk
was asked to give the opening keynote address at the conference in
Leiden, he contemplated committing the gravest heresy imaginable:
kicking off the inaugural gathering of the Society for Interdisciplinary
Placebo Studies by declaring that there was no such thing as the
placebo effect. When he broached this provocation in conversation with
me not long before the conference, it became clear that his point harked
directly back to Franklin: that the topic he and his colleagues studied
was created by the scientific establishment, and only in order to
exclude it — which means that they are always playing on hostile
terrain. Science is “designed to get rid of the husks and find the
kernels,” he told me. Much can be lost in the threshing — in particular,
Kaptchuk sometimes worries, the rituals embedded in the doctor-patient
encounter that he thinks are fundamental to the placebo effect, and that
he believes embody an aspect of medicine that has disappeared as
scientists and doctors pursue the course laid by Franklin’s commission.
“Medical care is a moral act,” he says, in which a suffering person puts
his or her fate in the hands of a trusted healer.
“I
don’t love science,” Kaptchuk told me. “I want to know what heals
people.” Science may not be the only way to understand illness and
healing, but it is the established way. “That’s where the power is,”
Kaptchuk says. That instinct is why he left his position as director of a
pain clinic in 1990 to join Harvard — and it’s why he was delighted
when, in 2010, he was contacted by Kathryn Hall, a molecular biologist.
Here was someone with an interest in his topic who was also an expert in
molecules, and who might serve as an emissary to help usher the placebo
into the medical establishment.
Hall’s
own journey into placebo studies began 15 years before her meeting with
Kaptchuk, when she developed a bad case of carpal tunnel syndrome.
Wearing a wrist brace didn’t help, and neither did over-the-counter
drugs or the codeine her doctor prescribed. When a friend suggested she
visit an acupuncturist, Hall balked at the idea of such an unscientific
approach. But faced with the alternative, surgery, she decided to make
an appointment. “I was there for maybe 10 minutes,” she recalls, “when
she stuck a needle here” — Hall points to a spot on her forearm — “and
this awful pain just shot through my arm.” But then the pain receded and
her symptoms disappeared, as if they had been carried away on the tide.
She received a few more treatments, during which the acupuncturist
taught her how to manipulate a spot near her elbow if the pain recurred.
Hall needed the fix from time to time, but the problem mostly just went
away.
“I
couldn’t believe it,” she told me. “Two years of gross drugs, and then
just one treatment.” All these years later, she’s still wonder-struck.
“What was that?” she asks. “Rub the spot, and the pain just goes away?”
Hall
was working for a drug company at the time, but she soon left to get a
master’s degree in visual arts, after which she started a
documentary-production company. She was telling her carpal-tunnel story
to a friend one day and recounted how the acupuncturist had climbed up
on the table with her. (“I was like, ‘Oh, my God, what is this woman
doing?’ ” she told me. “It was very dramatic.”) She’d never been able to
understand how the treatment worked, and this memory led her to wonder
out loud if maybe the drama itself had something to do with the outcome.
Her
friend suggested she might find some answers in Ted Kaptchuk’s work.
She picked up his book about Chinese medicine, “The Web that Has No
Weaver,” in which he mentioned the possibility that placebo effects
figure strongly in acupuncture, and then she read a study he had
conducted that put that question to the test.
Kaptchuk
had divided people with irritable bowel syndrome into three groups. In
one, acupuncturists went through all the motions of treatment, but used a
device that only appeared to insert a needle. Subjects in a second
group also got sham acupuncture, but delivered with more elaborate
doctor-patient interaction than the first group received. A third group
was given no treatment at all. At the end of the trial, both treatment
groups improved more than the no-treatment group, and the “high
interaction” group did best of all.
Kaptchuk,
who before joining Harvard had been an acupuncturist in private
practice, wasn’t particularly disturbed by the finding that his own
profession worked even when needles were not actually inserted; he’d
never thought that placebo treatments were fake medicine. He was more
interested in how the strength of the treatment varied with the quality
and quantity of interaction between the healer and the patient — the
drama, in other words. Hall reached out to him shortly after she read
the paper.
The findings of the I.B.S.
study were in keeping with a hypothesis Kaptchuk had formed over the
years: that the placebo effect is a biological response to an act of
caring; that somehow the encounter itself calls forth healing and that
the more intense and focused it is, the more healing it evokes. He
elaborated on this idea in a comparative study of conventional medicine,
acupuncture and Navajo “chantway rituals,” in which healers lead
storytelling ceremonies for the sick. He argued that all three
approaches unfold in a space set aside for the purpose and proceed as if
according to a script, with prescribed roles for every participant.
Each modality, in other words, is its own kind of ritual, and Kaptchuk
suggested that the ritual itself is part of what makes the procedure
effective, as if the combined experiences of the healer and the patient,
reinforced by the special-but-familiar surroundings, evoke a healing
response that operates independently of the treatment’s specifics.
“Rituals trigger specific neurobiological pathways that specifically
modulate bodily sensations, symptoms and emotions,” he wrote. “It seems
that if the mind can be persuaded, the body can sometimes act
accordingly.” He ended that paper with a call for further scientific
study of the nexus between ritual and healing.
When
Hall contacted him, she seemed like a perfect addition to the team he
was assembling to do just that. He even had an idea of exactly how she
could help. In the course of conducting the study, Kaptchuk had taken
DNA samples from subjects in hopes of finding some molecular pattern
among the responses. This was an investigation tailor-made to Hall’s
expertise, and she agreed to take it on. Of course, the genome is vast,
and it was hard to know where to begin — until, she says, she and
Kaptchuk attended a talk in which a colleague presented evidence that an
enzyme called COMT affected people’s response to pain and painkillers.
Levels of that enzyme, Hall already knew, were also correlated with
Parkinson’s disease, depression and schizophrenia, and in clinical
trials people with those conditions had shown a strong placebo response.
When they heard that COMT was also correlated with pain response —
another area with significant placebo effects — Hall recalls, “Ted and I
looked at each other and were like: ‘That’s it! That’s it!’ ”
It
is not possible to assay levels of COMT directly in a living brain, but
there is a snippet of the genome called rs4680 that governs the
production of the enzyme, and that varies from one person to another:
One variant predicts low levels of COMT, while another predicts high
levels. When Hall analyzed the I.B.S. patients’ DNA, she found a
distinct trend. Those with the high-COMT variant had the weakest placebo
responses, and those with the opposite variant had the strongest. These
effects were compounded by the amount of interaction each patient got:
For instance, low-COMT, high-interaction patients fared best of all, but
the low-COMT subjects who were placed in the no-treatment group did worse
than the other genotypes in that group. They were, in other words, more
sensitive to the impact of the relationship with the healer.
The
discovery of this genetic correlation to placebo response set Hall off
on a continuing effort to identify the biochemical ensemble she calls
the placebome — the term reflecting her belief that it will one day take
its place among the other important “-omes” of medical science, from
the genome to the microbiome. The rs4680 gene snippet is one of a group
that governs the production of COMT, and COMT is one of a number of
enzymes that determine levels of catecholamines, a group of brain
chemicals that includes dopamine and epinephrine. (Low COMT tends to
mean higher levels of dopamine, and vice versa.) Hall points out that
the catecholamines are associated with stress, as well as with reward
and good feeling, which bolsters the possibility that the placebome
plays an important role in illness and health, especially in the
chronic, stress-related conditions that are most susceptible to placebo
effects.
Her
findings take their place among other results from neuroscientists that
strengthen the placebo’s claim to a place at the medical table, in
particular studies using f.M.R.I. machines that have found consistent
patterns of brain activation in placebo responders. “For years, we
thought of the placebo effect as the work of imagination,” Hall says.
“Now through imaging you can literally see the brain lighting up when
you give someone a sugar pill.”
One group with
a particularly keen interest in those brain images, as Hall well knows,
is her former employers in the pharmaceutical industry. The placebo
effect has been plaguing their business for more than a half-century —
since the placebo-controlled study became the clinical-trial gold
standard, requiring a new drug to demonstrate a significant therapeutic
benefit over placebo to gain F.D.A. approval.
That’s
a bar that is becoming ever more difficult to surmount, because the
placebo effect seems to be becoming stronger as time goes on. A 2015
study published in the journal Pain analyzed 84 clinical trials of pain
medication conducted between 1990 and 2013 and found that in some cases
the efficacy of placebo had grown sharply, narrowing the gap with the
drugs’ effect from 27 percent on average to just 9 percent. The only
studies in which this increase was detected were conducted in the United
States, which has spawned a variety of theories to explain the
phenomenon: that patients in the United States, one of only two
countries where medications are allowed to be marketed directly to
consumers, have been conditioned to expect greater benefit from drugs;
or that the larger and longer-duration trials more common in America
have led to their often being farmed out to contract organizations whose
nurses’ only job is to conduct the trial, perhaps fostering a more
placebo-triggering therapeutic interaction.
Whatever
the reason, a result is that drugs that pass the first couple of stages
of the F.D.A. approval process founder more and more frequently in the
larger late-stage trials; more than 90 percent of pain medications now
fail at this stage. The industry would be delighted if it were able to
identify placebo responders — say, by their genome — and exclude them
from clinical trials.
That
may seem like putting a thumb on the scale for drugs, but under the
logic of the drug-approval regime, to eliminate placebo effects is not
to cheat; it merely reduces the noise in order for the drug’s signal to
be heard more clearly. That simple logic, however, may not hold up as
Hall continues her research into the genetic basis of the placebo.
Indeed, that research may have deeper implications for clinical drug
trials, and for the drugs themselves, than pharma companies might
expect.
Since 2013, Hall has been
involved with the Women’s Health Study, which has tracked the
cardiovascular health of nearly 40,000 women over more than 20 years.
The subjects were randomly divided into four groups, following standard
clinical-trial protocol, and received a daily dose of either vitamin E,
aspirin, vitamin E with aspirin or a placebo. A subset also had their
DNA sampled — which, Hall realized, offered her a vastly larger genetic
database to plumb for markers correlated to placebo response. Analyzing
the data amassed during the first 10 years of the study, Hall found that
the women with the low-COMT gene variant had significantly higher rates
of heart disease than women with the high-COMT variant, and that the
risk was reduced for those low-COMT women who received the active
treatments but not in those given placebos. Among high-COMT people, the
results were the inverse: Women taking placebos had the lowest rates of
disease; people in the treatment arms had an increased risk.
These
findings in some ways seem to confound the results of the I.B.S. study,
in which it was the low-COMT patients who benefited most from the
placebo. But, Hall argues, what’s important isn’t the direction of the
effect, but rather that there is
an effect, one that varies depending on genotype — and that the same
gene variant also seems to determine the relative effectiveness of the
drug. This outcome contradicts the logic underlying clinical trials. It
suggests that placebo and drug do not involve separate processes, one
psychological and the other physical, that add up to the overall
effectiveness of the treatment; rather, they may both operate on the
same biochemical pathway — the one governed in part by the COMT gene.
Hall
has begun to think that the placebome will wind up essentially being a
chemical pathway along which healing signals travel — and not only to
the mind, as an experience of feeling better, but also to the body. This
pathway may be where the brain translates the act of caring into
physical healing, turning on the biological processes that relieve pain,
reduce inflammation and promote health, especially in chronic and
stress-related illnesses — like irritable bowel syndrome and some heart
diseases. If the brain employs this same pathway in response to drugs
and placebos, then of course it is possible that they might work
together, like convoys of drafting trucks, to traverse the territory.
But it is also possible that they will encroach on one another, that
there will be traffic jams in the pathway.
What
if, Hall wonders, a treatment fails to work not because the drug and
the individual are biochemically incompatible, but rather because in
some people the drug interferes with the placebo response, which if
properly used might reduce disease? Or conversely, what if the placebo
response is, in people with a different variant, working against drug
treatments, which would mean that a change in the psychosocial context
could make the drug more effective? Everyone may respond to the clinical
setting, but there is no reason to think that the response is always
positive. According to Hall’s new way of thinking, the placebo effect is
not just some constant to be subtracted from the drug effect but an
intrinsic part of a complex interaction among genes, drugs and mind. And
if she’s right, then one of the cornerstones of modern medicine — the
placebo-controlled clinical trial — is deeply flawed.
When Kathryn Hall
told Ted Kaptchuk what she was finding as she explored the relationship
of COMT to the placebo response, he was galvanized. “Get this molecule
on the map!” he urged her. It’s not hard to understand his excitement.
More than two centuries after d’Eslon suggested that scientists turn
their attention directly to the placebo effect, she did exactly that and
came up with a finding that might have persuaded even Ben Franklin.
But
Kaptchuk also has a deeper unease about Hall’s discovery. The placebo
effect can’t be totally reduced to its molecules, he feels certain — and
while research like Hall’s will surely enhance its credibility, he also
sees a risk in playing his game on scientific turf. “Once you start
measuring the placebo effect in a quantitative way,” he says, “you’re
transforming it to be something other than what it is. You suck out what
was previously there and turn it into science.” Reduced to its
molecules, he fears, the placebo effect may become “yet another thing on
the conveyor belt of routinized care.”
“We’re
dancing with the devil here,” Kaptchuk once told me, by way of
demonstrating that he was aware of the risks he’s taking in using
science to investigate a phenomenon it defined only to exclude.
Kaptchuk, an observant Jew who is a student of both the Torah and the
Talmud, later modified his comment. It’s more like Jacob wrestling with
the angel, he said — a battle that Jacob won, but only at the expense of
a hip injury that left him lame for the rest of his life.
Indeed,
Kaptchuk seems wounded when he complains about the pervasiveness of
research that uses healthy volunteers in academic settings, as if the
response to mild pain inflicted on an undergraduate participating in an
on-campus experiment is somehow comparable to the despair often suffered
by people with chronic, intractable pain. He becomes annoyed when he
talks about how quickly some of his colleagues want to move from these
studies to clinical recommendations. And he can even be disparaging of
his own work, wondering, for instance, whether the study in which
placebos were openly given to irritable bowel syndrome patients
succeeded only because it convinced the subjects that the sugar was
really a drug. But it’s the prospect of what will become of his
findings, and of the placebo, as they make their way into clinical
practice, that really seems to torment him.
Kaptchuk
may wish “to help reconfigure biomedicine by rejecting the idea that
healing is only the application of mechanical tools.” He may believe
that healing is a moral act in which “caring in the context of hope
qualitatively changes clinical outcomes.” He may be convinced that the
relationship kindled by the encounter between a suffering person and a
healer is a central, and almost entirely overlooked, component of
medical treatment. And he may have dedicated the last 20 years of his
life to persuading the medical establishment to listen to him. But he
may also come to regret the outcome.
After
all, if Hall is right that clinician warmth is especially effective
with a certain genotype, then, as she wrote in the paper presenting her
findings from the I.B.S./sham-acupuncture study, it is also true that a
different group will “derive minimum benefit” from “empathic
attentions.” Should medical rituals be doled out according to genotype,
with warmth and caring withheld in order to clear the way for the drugs?
And if she is correct that a certain ensemble of neurochemical events
underlies the placebo effect, then what is to stop a drug company from
manufacturing a drug — a real drug, that is — that activates the same
process pharmacologically? Welcomed back into the medical fold, the
placebo effect may raise enough mischief to make Kaptchuk rue its
return, and bewilder patients when they discover that their doctor’s
bedside manner is tailored to their genes.
For
the most part, most days, Kaptchuk manages to keep his qualms to
himself, to carry on as if he were fully confident that scientific
inquiry can restore the moral dimension to medicine. But the
precariousness of his endeavors is never far from his mind. “Will this
work destroy the stuff that actually has to do with wisdom,
preciousness, imagination, the things that are actually critical to who
we are as human beings?” he asks. His answer: “I don’t know, but I have
to believe there is an infinite reserve of wisdom and imagination that
will resist being reduced to simple materialistic explanations.”
The
ability to hold two contradictory thoughts in mind at the same time
seems to come naturally to Kaptchuk, but he may overestimate its
prevalence in the rest of us. Even if his optimism is well placed,
however, there’s nothing like being sick to make a person toss that kind
of intelligence aside in favor of the certainties offered by modern
medicine. Indeed, it’s exactly that yearning that sickness seems to
awaken and that our healers, imbued with the power of science, purport
to provide, no imagination required. Armed with our confidence in them,
we’re pleased to give ourselves over to their ministrations, and pleased
to believe that it’s the molecules, and the molecules alone, that are
healing us. People do like to be cheated, after all.
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